Risk Management Tips – Experien case studies

28 August 2019

Case study one

As part of a health fund’s regular conduct review into their providers’ claiming patterns, a general dentist was asked to produce copies of various documents, including full customer records, treatment plans, patient notes, dental charts, x-rays, payment transactions, customer invoices and signed receipts.

It is important to note that such requests are expressly permitted by section 4 of the HICAPS Provider Agreement Terms and Conditions (T&Cs). The T&Cs require that a provider must, on the request of a health fund, make available evidence including treatment plans, appointment schedules, signed receipts and other supporting documentation, as requested, within 10 days of the request.

In this case, the purpose of the review was primarily to ensure that the health fund was paying the correct benefits for services performed by the dentist.

While the dentist did keep detailed and comprehensive notes and records, the review still found a number of discrepancies in relation to the dentist’s records and practices which resulted in the health fund issuing a significant refund request for excess benefits allegedly paid.

Significantly, a number of the discrepancies uncovered were due to a minute or technical error in record keeping, a common issue for many general dentists. Some of the issues identified in this case involved discrepancies between:

  • customer records and HICAPS transactions;
  • treatment notes and services claimed; and
  • treatment notes and billing dates.

Case study two

Likewise to the case study above, this case also involved a review into the practices of a general dentist to determine whether accurate and appropriate benefits were being paid.

Unfortunately, however, the dentist in this instance did not keep quite as detailed and comprehensive notes as the dentist in the first case study. He/she also failed to notify the insurer of the review and refund request until some time later, when investigations were already well underway.

As a result, the extent to which we were able to assist the dentist was restricted by reason of the pre-existing correspondence between the parties. Discussions had already occurred between the dentist and the health fund which attempted to explain and justify the discrepancies uncovered as part of the review.


In the first case, the detailed and comprehensive notes and records of the dentist allowed us to promptly assist the dentist in providing a detailed and persuasive response to the health fund’s refund request.

We were able to address the discrepancies individually to explain and justify why certain information was missing or incorrectly inputted in the first instance. In light of this response the health fund significantly reduced the refund request amount and did not take any further action against the dentist. The response received was appreciated by the health fund which helped to ensure the preservation of an ongoing relationship with the dentist – much to the gratitude of both parties.

In the second case, while we were still able to persuade the health fund to apply a discount to the refund request, the difficulty of this task was far greater due to the late notification and prior correspondence between the dentist and the health fund.

Without our intervention, at this stage of the review, it is very likely that further discussions would have prevented any possible discount being applied and, potentially, may have resulted in a broader investigation into the practices of the dentist being conducted, or even may have resulted in a complaint against the dentist being made.


Some key implications from these two case examples are:

  • The importance of keeping complete and accurate dental records to enable justification of the treatment provided to patients to health funds to support the health benefits claimed.
  • The importance of keeping complete and accurate financial records, including signed HICAPS receipts and invoices, and ensuring that what is stated on these documents accurately depicts the services provided and recorded on the dental records.
  • Any review or audit should be immediately actioned and you should ensure that any deadline provided by the health fund is met. If that is not possible, you should ensure that an extension of time is obtained from the health fund well prior to the expiration of any deadline.
  • You should immediately notify Experien of any health fund reviews (or other circumstances that might give rise to a claim on your insurance policy generally) to enable it to assist you with defending the inquiry.
  • There are serious implications which may follow should the review not be dealt with promptly, including the health fund terminating your provider status, the health fund reporting you to regulatory body or the health fund seeking repayment of any excess benefits paid.

For further information regarding dental record keeping obligations please see Barry.Nilsson. and Experien’s ‘Refresher Guide to Record Keeping’.

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